Clinical Governance Development Committee October 2007 Dr Foster RTM Alerts Progress Report 1. Background Information 1.1. Initial review of the tool in November 2006, and subsequent queries in January and August 2007 identified 39 individual areas, referred to as alerts where the Trust appeared to be at variance with the benchmark of English Trust. Letters have been sent to the appropriate Divisional Medical Directors and Clinical Directors, advising them of this and inviting them to treat the alert as a need to understand an issue in more depth rather than a cause for concern at this stage. 1.2. Divisional Medical Directors have also been provided with regular summaries of alerts within their divisions, with offers of support and assistance from trained clinical audit staff to understand the data and where necessary, to advance any projects to investigate the alerts. Regular updates on the progress of investigations into alerts are tkaen to divsional board meeting and divisional clinical governance meetings. 1.3. These alerts relate to the briefing given to the Clinical Governance Assurance Committee in July 2007. 2. Progress to Date 2.1. Of the alerts, 10 have been identified as CUSUM alerts (i.e. trend alerts), these are isolated incidence of variation, not leading to repeated occurabces and not statistically significant in variance to the English benchmark. These alerts continued to be monitored to identify continuing trends and/or paterns. 2.2. Of these 10 CUSUM alerts, 7 no longer register on the RTM tool as CUSUM alerts, with alerts still present for: - - Cancer of bronchus, re-admissions - Endoscopic resection of outlet of male bladder, - Diagnostic endoscopic examination of bladder, 2.3. Investigations have been completed on 8 alerts, with investigating clinicians indicating that their conclusions are that no clinical cause for concern in 7 alerts, but the investigating clinican indicated they were aware of an organisation issues in a single alert (see 3.1 below). 2.4. Investigation and audit has commenced on a further 12 alerts, with the areas identified as being at variance with the English benchmark being incorporated into divisional clinical audit programmes. 2.5. The remaining 6 alerts have proved very complicated and difficult to understand and relate to maternity services. Audit against the benchmark provided by Dr Foster has outstanding questions about the analysis. The Dr Foster RTM support team has been involved and investigations have been
suspended. Dr Foster custemer support is ecpected to be in palce by November 2007, in the mean time arrangeemtns have been made with the national lead for customer support to meet and discuss this issue on 29 th October 2007. 2.6. New alerts have been issued in August 2007 for: - - Cancer of prostate, - Chronic renal failure, - Heart valve disorders, - Leukaemia, re-admission - Non-Hodgkin's lymphoma, re-admission - Pleurisy, pneumothorax, pulmonary collapse, - Appedicectomy, - CABG (isolated first time), - Excision of Dupuytren's contracture, re-admission - Excision of lesion of skin, re-admission - Excision of vas deferens, - Laparascopic cholecystectomy, - Operations on peptic ulcer, - Transluminal operations on femoral artery, 3. Action Required 3.1. Note that, thus far, the only cause for concern highlighted by investigations relates to for primary repair tendon, the issue highlighted by the Clinical Director Burns and Plastic was inadequate theatre access leading to longer pre-operative stays for certain patients. The Directorate Manager has advised re-configuration in theatre access commenced August 2007, which he considers should resolve this problem. 3.2. Note surveillance of alerts remains ongoing and carried out by the Clinical Governance Manager Clinical Audit & Effectiveness, new alerts are reported directly to relevant Clinical Directors, Divsional Medical Directors with regular progress reports made to the Clinical Governance Development Committee and Clinical Governance Assurance Committee. 3.3. Note that of the 98 users registered and trained to use the tool, only 11 have used the tool at all within the last 3 months and only 2 of them were clinicans. This may indicate that it may be useful to re-examine how the tool is used within the organisation. David Watson Clinical Governance Manager Clinical Audit & Effectiveness
Division of Heart & Lung Other lower respiratory disease Chest Medicine Investigation Underway - Dr Armitage (SpR in Chest medicine) will be undertaking the audits undertaking a retrospective case note study on patients who exceeded the predicted. The audit will be conducted throughout September/ October and be completed by early November. Peripheral and visceral atherosclerosis Vascular Full review of case notes by revealed patients were mainly urgent admissions with limb threatening problems, requiring complex open surgery. Clinical Director indicated that while he had no concern regarding the of these patients, coding and risk adjustment may not be sufficient for these complex cases. Other upper respiratory disease Mortality Chest Medicine Other open heart operations Cardiothoracic Clinical Director identified as heart transplant patients, explaining their long. Non-specific chest pain Chest Medicine Investigation Underway - Dr Armitage (SpR in Chest medicine) will be undertaking the audits undertaking a retrospective case note study on patients who exceeded the predicted. The audit will be conducted throughout September/ October and be completed by early November.
Asthma Chest Medicine Review of data identified variance was caused by high risk asthma patients cared for by Dr Niven. Asthma Re-admission Chest Medicine COPD & bronchiotasis Re-admission Chest Medicine Cancer of bronchus Re-admission Chest Medicine Contrast radiology or catheterisation of heart Re-admission Cardiothoracic Heart valve disorders Cardiothoracic Non-Hodgkin s lymphoma Re-admission Cardiothoracic Review of data revealed that this represents a specialist CT surgical department dealing with a small subset of patients with complex disease in small numbers. Almost by definition these types of patients will have multiple hospital admissions for diagnosis and treatment Review of data revealed that this represents a specialist CT surgical department dealing with a
Pleurisy, pneumothorax, pulmonary collapse Cardiothoracic CABG (isolated, 1 st Time) Cardiothoracic Transluminal operations on femoral artery Vascular small subset of patients with complex disease in small numbers. Almost by definition these types of patients will have multiple hospital admissions for diagnosis and treatment Investigation Under Way Review of data revealed that this represents a specialist CT surgical department dealing with a small subset of patients with complex disease in small numbers. Almost by definition these types of patients will have multiple hospital admissions for diagnosis and treatment Investigation Under Way Division of Medicine Fracture neck of femur Gen Med Review of data and case notes revealed that these patients spent an average of 20 days on the orthopaedic ward pre-transfer (maybe indicating clinical complexity at an early stage), and that the great majority went home - which takes longer than nursing home placement in these people. Additionally, Trafford patients, who have no access to intermediate care facilities, took up the majority of beds on F7 - Manchester residents have
access to Buccleuch Lodge & the Peele, which enables discharge from hospital at an earlier stage. Cancer of colon Gen Med alert was present, relative risk score was not statistically significant. Acute bronchitis Gen Med alert was present, relative risk score was not statistically significant. Chronic renal failure Gen Med Investigation Under Way Division of 1 Primary repair of tendon Burns & Plastics Clinical Director has indicated that issues are due to theatre access issues Primary repair of tendon Re-admission Burns & Plastics Review of data and case notes indicates that whilst some re attendances related to the primary procedure, at least half were non related, i.e. re injury, different injury etc. Excision of Dupuytern s Re-admission Orthopaedics Investigation Under Way contracture Excision of lesion of skin Re-admission Burns & Plastics Investigation Under Way
Division of 2 Therapeutic endoscopic procedures on ureter Urology Review of data identified large proportion of patients with co-morbidity/high risk factors, some coding issues. Other intravenous injection Paediatrics Investigation suspended awaiting clarification Short gestation, low weight, fetal growth retardation Obstetrics & Gynaecology Investigation suspended awaiting clarification Delivery Obstetrics & Gynaecology Investigation suspended awaiting clarification Other perinatal conditions Paediatrics Investigation suspended awaiting clarification Normal pregnancy and/or delivery Obstetrics & Gynaecology Investigation suspended awaiting clarification Live birth Paediatrics Investigation suspended awaiting clarification Endoscopic resection of outlet of male bladder Diagnostic endoscopic examination of bladder Cancer of ovary Obstetrics & Gynaecology Urology alert was present, relative risk score was not statistically significant Urology alert was present, relative risk score was not statistically significant
alert was present, relative risk score was not statistically significant Diagnostic transluminal operations on vein Mortality Urology Review of single case by Consultant Urological Surgeon concluded procedure unrelated to outcome and was clinical care optimal. Cancer of prostate Urology Investigation Under Way Appedicectomy General Investigation Under Way Excision of vas deferns Urology Investigation Under Way Laparoscopic cholecystectomy General Investigation Under Way Operations on peptic ulcer General Investigation Under Way Division of Clinical Support Leukaemia Re-admission Pathology Investigation Under Way Other blood transfusions Re-admission Pathology Investigation Under Way